Synopsis On 10March 1995, the general cargo vessel SANTIAGO DE CUBA, carrying 5,264tonnes of miscellaneous steel products, was en route from Sorel, Quebec, to the port of Cacouna, Quebec. Late in the day, the boatswain (bosun) and one deckhand proceeded to No.1 hold to close the hatch. While the deckhand climbed down into the hold to disengage the cargo hook that was holding the cradle, the bosun went toward the crane to take up his position. However, the bosun fell and landed on the lower 'tween-deck. He was given first aid, but he died while being carried to the ship's hospital. The ship's doctor was unable to revive him and pronounced him dead. Factual Information Particulars of the Vessel Port of Registry St.Petersburg, Russia Propulsion One MAN engine, 7,061kW, driving a single fixed-pitch propeller The SANTIAGO DE CUBA has five holds, four of which are forward of the accommodation. No.1 hold is in the raised foredeck; there is a crane on the raised deck to starboard of the centre line and aft of the hatchway to No.1 hold. On 10March 1995, while the vessel was sailing through ice-infested waters with two pilots on board, the engine-room staff was carrying out repairs to the electro-hydraulic system used to open the lower 'tween-deck hatch covers. To gain access to the system, a cradle is hung from the cargo hook of the service crane for No.1 hold. At about 1800(1), the bosun informed the fourth engineer that he had to close No.1 hold. In the company of a deckhand, the bosun arrived on the foredeck at about 1825 and told the deckhand to climb down into the hold and unhook the cargo hook from the cradle. Before entering the hold via the port manhole, the deckhand saw the bosun going toward the No.1 crane. When he arrived at the bottom of the hold, the deckhand called out to the bosun to lower the cargo hook, but there was no answer to his calls. The deckhand waited a few minutes, but as there was still no sign of the bosun, he decided to climb back up to the main deck. When he reached the deck, the deckhand saw no one near the hatchway. The crane door was open, but the electric drive motor was not turned on. The deckhand went to the accommodation to look for the bosun. Still looking for the bosun, he returned to No.1 hold and encountered the fourth engineer and the greaser on the 'tween-deck; no one had yet seen the bosun. The deckhand climbed back up the same ladders he had descended and returned to the accommodation. Still he was unable to find the bosun, and around 1855, he returned to No.1 hold for the third time. When the repairs were completed, the fourth engineer, the greaser and the deckhand went back to the accommodation; the deckhand retired to his cabin without reporting the bosun's disappearance. At about 1900, the chief engineer and the fourth engineer went to No.1 hold to inspect the repairs. They proceeded via the ladders located aft of No.1 hold, and they had a flashlight with them. Having completed their inspection around 1920, they climbed back up to the lower 'tween-deck via the ladder on the collision bulkhead. The two engineers heard something that sounded like a groan, followed by murmuring, which they managed to locate in the aft starboard section of the 'tween-deck. The two engineers found the bosun lying on his left side with the hood of his parka over his head. While he tried to get up, he was asked what had happened; he did not reply, but instead asked for help to get up and out of the hold. The chief engineer went toward the accommodation to summon assistance. At about 1930, the ship's doctor arrived at the scene and observed that the bosun's pulse was weak but very fast. The bosun was given a painkiller by injection, and placed on a stretcher to be evacuated on the cradle. The injured was carried to the ship's hospital around 2000, where the doctor attempted to revive him. His efforts were in vain, and, at 2015, the doctor pronounced him dead.